It is a sign of insecurity when the NHS wants to use an army-style conscription policy to retain medical graduates.<1> It shows the NHS lacks faith in competing with medical employers overseas. In fairness, many of my British colleagues have unrealistic expectations of their career prospects overseas. I have worked in both the British and North America healthcare systems, and would like to debunk some myths here. The followings are some comments I heard from my British colleagues:
"I will have a better work-life balance overseas." In Toronto, Canada, for example, medical residents (equivalent to junior doctors in the UK) can have up to seven 24-hour in-hospital on-call shifts every 28 days.<2> They can be on call every second weekend.
"I will have a better pay overseas." Foundation year 2 doctors in the UK are paid about £46/hour for a locum on-call shift,<3> whereas medical residents in Toronto are paid a standard stipend of $116/day for a 24-hour on-call shift, equivalent to less than £3/hour.<2>
“I will have a better opportunity to be selected in a posh speciality overseas.” In 2017, the general practice residency program in British Columbia had 52 positions for 1045 international applicants.<4> There is no trust grade or senior associate specialist posts in North America - you are either a resident or fully qualified attending. Alternatively, you can be a jobless doctor.
“My British medical degree will be highly valued overseas.” Indeed, I have heard many North American doctors calling the international medical training very “hands-off.” Ironically, most of the people that make this comment never work in the UK. Ironically, North American doctors do not need to perform many ward procedures, such as venipuncture, intravenous cannulation, nasogastric tube insertion, and writing drug charts, because they are duties of nurses and ward clerks there. People apparently think the NHS pays junior doctors to just go to lectures and study in libraries. At times, our British work ethics are called into questions. I was asked whether I can manage heavy workload, in view of the recent junior doctor strike in England.
Despite these, in my humble opinion, the North Americans are superior in their quality of medical training. For instance, a first-year resident takes referrals, consults new patients, and reviews his assessment and management plans with his senior. In return, his senior educates the junior on the spot, provides timely feedback on the consultations, and then finalizes the junior's management plans. This is very different from the NHS in which a FY1 doctor could be mainly used as a clerking machine, cannula technician, and discharge typewriter.<5> A FY1's differential diagnoses of the condition is rarely appreciated, and could be misinterpreted as “arrogantly calling the shots” in front of the seniors. In North America, doctors may be offered an educational grant for delivering formal teaching, which is an attractive incentive to strive for excellence in education. In contrast, British doctors may be given simply a certificate of appreciation for delivering formal teaching. An NHS institution could struggle to find lecturers to fill the teaching schedule.<6>
The North Americans emphasize on patient safety. For instance, British junior doctors may often struggle to find anyone to help with blood taking, even in acute situations - this rarely happens in North America. The health professionals there are very skilled and keen to expand their scope of practice. When managing referrals, the North American non-admitting team can only suggest orders, but not starting or changing orders for patients. This way, the admitting team decides what is suitable. This setup also prevents the admitting team from dumping administrative work, such as preparation of discharge summaries, to another team.
I understand that the NHS wants reassurance in their investment in medical training, and it is heartbreaking to see their training products departing from the UK. With limited funding, it is tough for the NHS to financially compete with employers overseas. Nevertheless, the NHS can make the work environment more favourable and improve the morale and job satisfaction of its employees. Coercing employees to stay would only further lower the morale at work, and make employees flee as soon as their conscription contracts expire. Many British trained consultants I met stay in the NHS because of family reasons. If every employee were respected as a valuable family member of the NHS, would the employees still be eager to leave?
References
1. Rimmer A. Plan for army-style conscription of doctors is reconsidered. BMJ. 2017;358:j3839.
2. Call stipends FAQs. Toronto, Canada: University of Toronto; 2016; cited [Nov 17, 2017]. Available from: http://pg.postmd.utoronto.ca/current-trainees/while-youre-training/acces....
3. Rimmer A. Locum pay rates have risen despite hourly rate cap. BMJ. 2017;356:j135.
4. UBC IMG statistics. Vancouver, Canada: University of British Columbia; 2017; cited [Nov 17, 2017]. Available from: http://carms.familymed.ubc.ca/img-applicants/img-statistics/.
5. Yeung EYH. How are junior doctors supposed to learn without the opportunity? BMJ. 2017;359:j5057.
6. Junior doctors don’t get enough teaching. BMJ. 2011;342:d2246.
Rapid Response:
I find the NHS lack of faith disturbing
It is a sign of insecurity when the NHS wants to use an army-style conscription policy to retain medical graduates.<1> It shows the NHS lacks faith in competing with medical employers overseas. In fairness, many of my British colleagues have unrealistic expectations of their career prospects overseas. I have worked in both the British and North America healthcare systems, and would like to debunk some myths here. The followings are some comments I heard from my British colleagues:
"I will have a better work-life balance overseas." In Toronto, Canada, for example, medical residents (equivalent to junior doctors in the UK) can have up to seven 24-hour in-hospital on-call shifts every 28 days.<2> They can be on call every second weekend.
"I will have a better pay overseas." Foundation year 2 doctors in the UK are paid about £46/hour for a locum on-call shift,<3> whereas medical residents in Toronto are paid a standard stipend of $116/day for a 24-hour on-call shift, equivalent to less than £3/hour.<2>
“I will have a better opportunity to be selected in a posh speciality overseas.” In 2017, the general practice residency program in British Columbia had 52 positions for 1045 international applicants.<4> There is no trust grade or senior associate specialist posts in North America - you are either a resident or fully qualified attending. Alternatively, you can be a jobless doctor.
“My British medical degree will be highly valued overseas.” Indeed, I have heard many North American doctors calling the international medical training very “hands-off.” Ironically, most of the people that make this comment never work in the UK. Ironically, North American doctors do not need to perform many ward procedures, such as venipuncture, intravenous cannulation, nasogastric tube insertion, and writing drug charts, because they are duties of nurses and ward clerks there. People apparently think the NHS pays junior doctors to just go to lectures and study in libraries. At times, our British work ethics are called into questions. I was asked whether I can manage heavy workload, in view of the recent junior doctor strike in England.
Despite these, in my humble opinion, the North Americans are superior in their quality of medical training. For instance, a first-year resident takes referrals, consults new patients, and reviews his assessment and management plans with his senior. In return, his senior educates the junior on the spot, provides timely feedback on the consultations, and then finalizes the junior's management plans. This is very different from the NHS in which a FY1 doctor could be mainly used as a clerking machine, cannula technician, and discharge typewriter.<5> A FY1's differential diagnoses of the condition is rarely appreciated, and could be misinterpreted as “arrogantly calling the shots” in front of the seniors. In North America, doctors may be offered an educational grant for delivering formal teaching, which is an attractive incentive to strive for excellence in education. In contrast, British doctors may be given simply a certificate of appreciation for delivering formal teaching. An NHS institution could struggle to find lecturers to fill the teaching schedule.<6>
The North Americans emphasize on patient safety. For instance, British junior doctors may often struggle to find anyone to help with blood taking, even in acute situations - this rarely happens in North America. The health professionals there are very skilled and keen to expand their scope of practice. When managing referrals, the North American non-admitting team can only suggest orders, but not starting or changing orders for patients. This way, the admitting team decides what is suitable. This setup also prevents the admitting team from dumping administrative work, such as preparation of discharge summaries, to another team.
I understand that the NHS wants reassurance in their investment in medical training, and it is heartbreaking to see their training products departing from the UK. With limited funding, it is tough for the NHS to financially compete with employers overseas. Nevertheless, the NHS can make the work environment more favourable and improve the morale and job satisfaction of its employees. Coercing employees to stay would only further lower the morale at work, and make employees flee as soon as their conscription contracts expire. Many British trained consultants I met stay in the NHS because of family reasons. If every employee were respected as a valuable family member of the NHS, would the employees still be eager to leave?
References
1. Rimmer A. Plan for army-style conscription of doctors is reconsidered. BMJ. 2017;358:j3839.
2. Call stipends FAQs. Toronto, Canada: University of Toronto; 2016; cited [Nov 17, 2017]. Available from: http://pg.postmd.utoronto.ca/current-trainees/while-youre-training/acces....
3. Rimmer A. Locum pay rates have risen despite hourly rate cap. BMJ. 2017;356:j135.
4. UBC IMG statistics. Vancouver, Canada: University of British Columbia; 2017; cited [Nov 17, 2017]. Available from: http://carms.familymed.ubc.ca/img-applicants/img-statistics/.
5. Yeung EYH. How are junior doctors supposed to learn without the opportunity? BMJ. 2017;359:j5057.
6. Junior doctors don’t get enough teaching. BMJ. 2011;342:d2246.
Competing interests: No competing interests